Angle-closure glaucoma
ICD-10 H40.2 · ICD-11 9C61.3

Angle-Closure Glaucoma with Corneal Edema After Failed Medical IOP-Lowering Therapy: Next-Line Management

This protocol applies to the patient presenting with an occluded anterior chamber angle and symptomatic markedly elevated intraocular pressure whose acute medical treatment has not achieved the required goals—IOP remains uncontrolled, eye pain persists, and corneal edema has not cleared.

Clinical Presentation

Occluded anterior chamber angle with symptomatic markedly elevated IOP; eye pain, headache, nausea/vomiting, and blurred vision with halos; corneal edema, conjunctival and episcleral vascular congestion, and a mid-dilated pupil.

Previous Line Failed — Medical IOP-Lowering Therapy

Medical therapy to lower IOP—including aqueous-suppressant agents, parasympathomimetics, systemic hyperosmotic agents, mydriatics (where indicated), and corneal indentation—did not achieve the required targets: lowering of IOP, relief of eye pain, and clearing of corneal edema. This protocol defines the next step.

Next-Step Approach (Partial)

The next-line intervention is a laser-based procedure performed as soon as safely feasible to address the underlying pupillary block mechanism. The clinical goal is angle widening and flattening of the iris profile on gonioscopy. The complete structured regimen is available in the full protocol below.

Instant Access to Structured Evidence-Based Regimens

References

  • Acute angle-closure crisis (AACC): occluded angle with symptomatic high IOP
  • Symptoms of AACC include eye pain, headache, nausea/vomiting, and blurred vision with halos.
  • Clinical signs of AACC are markedly elevated IOP, corneal edema, conjunctival and episcleral vascular congestion, and/or a mid-dilated pupil.
  • Laser peripheral iridotomy should then be performed as soon as safely feasible.
  • Laser peripheral iridotomy (or incisional iridectomy) allows aqueous to bypass the pupillary block and eliminates the pressure gradient between the posterior and anterior chambers.
  • Laser peripheral iridotomy is the preferred surgical treatment because it has a favorable risk-benefit ratio.
  • It can also result in significant angle widening and iris-profile flattening.

DOI: 10.1016/j.ophtha.2025.12.030

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